Healthcare Provider Details

I. General information

NPI: 1548754724
Provider Name (Legal Business Name): MEDEXPRESS PRIMARY CARE SOUTH CAROLINA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 TWO NOTCH RD
LEXINGTON SC
29072
US

IV. Provider business mailing address

1001 CONSOL ENERGY DR
CANONSBURG PA
15317-6506
US

V. Phone/Fax

Practice location:
  • Phone: 803-951-5871
  • Fax: 803-951-5872
Mailing address:
  • Phone: 304-225-2500
  • Fax: 724-743-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BRETT GALL
Title or Position: DIRECTOR PAYOR CONTRACTING
Credential:
Phone: 304-225-2500